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The Interface Between Evidence Hierarchy and Clinical Practice Guidelines

This article explores the relationship between the hierarchy of evidence and attitudes towards clinical practice guidelines. It discusses the importance of critically analyzing evidence and the challenges posed by traditional hierarchies. The article also highlights key issues in evaluating guidelines and provides resources for evidence-based nursing initiatives.

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The Interface Between Evidence Hierarchy and Clinical Practice Guidelines

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  1. The interface between the hierarchy of evidence and attitudes to clinical practice guidelines Jayne James

  2. Background • Evidence for clinical health care practice can arise from a variety of sources • Evidence should not be automatically accepted but needs to be analysed (Earl-Slater 2001) • Needs of information society have acted as catalysts in the rapid growth of Evidence Based Medicine (Hewitt Taylor2002) • Evidence based medicine encompasses all health care professionals

  3. Evidence-based Medicine “Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” • It’s about integrating best available evidence from research with clinical expertise to enhance decisions (Sackett et al 1996)

  4. What “counts” as evidence? • Many authorities believe that the best evidence for effectiveness comes from a Randomised Controlled Trial (Gold standard) • A systematic review of RCTs is ranked as the top in most hierarchies A hierarchy is based on the premised that certain research designs are more prone to bias than others

  5. 1 Hierarchy of evidence(Earl Slater 2001) A/B Meta-analysis (summary statistic) and systematic review of randomised controlled trials C evidence from a RCT trial D case control trials (same as above except one group will not have subject of the hypothesis ie cancer) E cohort studies ( one group followed through over time no control group ) F Expert opinion

  6. Evidence Base Practice • Assumption of EBP is that the RCT is the best way to evaluate effectiveness of an intervention and better basis for decision- making Evidence from published research or published guidelines Clinical expertise

  7. Problems with traditional hierarchy in order to rate evidence lack of ‘human’ perspective lack of ‘user’ perspective depends on quantifiable evidence Does not take into account current available best evidence dismisses the art of Nursing Not embedded in a specific patient context No guarantee that just because it’s a clinical trial you have good results!

  8. 1990’s RCTs reveal mortality rates improved from 40% without ICD to 90% with an ICD at 3 years Psychological effects- only nurses experiences of caring Qualitative data revealed depression, anxiety fear of being alone Currently Quantitative data reveals psychological/ issues for patients Anecdotal/qual evidence regarding relative psychological effects Interventions to overcome and support not tested but based on experience Example from practice -Internal Cardioverter Defibrillator therapy

  9. Problems with rating evidence • Dominance of medical models of evidence at odds with holistic view of Health and Social care setting? • Quality could be defined differently dependent on who is looking at the evidence (Earl Slater 2001) • Depends on the context ie time is it current

  10. Now consider the following guideline • Using the traditional hierarchy of evidence how good a guideline do you think this is ? • Was it a local or national guideline does this make a difference ? • How was the hierarchy used within this? • Was this useful? • How did you rate the evidence within this document? • What evidence do you feel was missing?

  11. Key issues for your assignment • Tools for critical appraisal is crucial • Key areas include users perspective, currency, evidence base, who compiled this • Ethics of practitioners using guidelines • Reading around how to complete and evaluate this is very important

  12. Evidence based nursing initiatives • Evidence based nursing centres Centre for EBN at the University of York http://www.york.ac.uk/inst/crd/welcome.htm • Joanna Briggs Institute of evidence based nursing & midwifery http://www.joannabriggs.edu.au/ • Scharr (Evidence based practice on the net) • http://www.nettingtheevidence.org.uk/ • Information services NHS Centre for Reviews and dissemination* Cohrane Collaboration/Cochrane library & databases National Institute of Clinical Effectiveness Earl Slater(2001) Critical appraisal and hierarchies of the evidence British Journal of Clinical Governance 6 (1) 59-63

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